Healthcare Provider Details

I. General information

NPI: 1083907661
Provider Name (Legal Business Name): AMY MELISSA TIERNEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-5179
  • Fax: 503-905-0495
Mailing address:
  • Phone: 971-206-5179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD173899
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: